306005513-7-21-2025-22-AS-AORZ-DKJRJV-20250814130432

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306005513
Report Date: 07/21/2025
Date Signed: 07/21/2025 01:10:53 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/24/2021 and conducted by Evaluator Samer Haddadin

COMPLAINT CONTROL NUMBER: 22-AS-20210324151302

FACILITY NAME:	CARMEL VILLAGE RETIREMENT COMMUNITY		FACILITY NUMBER:	306005513
ADMINISTRATOR:	BENTON, DONALD		FACILITY TYPE:	740
ADDRESS:	17077 SAN MATEO		TELEPHONE:	(714) 962-6667
CITY:	FOUNTAIN VALLEY	STATE: CA	ZIP CODE:	92708
CAPACITY:	220	CENSUS: 189	DATE:	07/21/2025
		UNANNOUNCED	TIME BEGAN:	02:11 PM
MET WITH:	Laura Forman		TIME COMPLETED:	04:41 PM

ALLEGATION(S):

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Staff left resident in soiled clothing for extended periods of time
Staff did not safeguard residents personal belongings
Residents room was malodorous

INVESTIGATION FINDINGS:

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On July, 21, 2025 Licensing Program Analyst (LPA) Samer Haddadin conducted an unannounced complaint visit to investigate allegations that a "resident's room was malodorous," that "staff did not safeguard residents’ personal belongings," and that "staff left a resident in soiled clothing for extended periods." Upon arrival, LPA Haddadin was greeted, granted entry into the facility by Memory Care Director Laura Forman, and explained the purpose of the visit.
The investigation included a tour of the facility, a review of relevant documentation, and interviews with staff and residents. Specifically, this involved interviews with three staff members and three residents, as well as a review of resident and facility files.
Regarding the allegation that a "resident's room was malodorous," none of the three residents and none of the three staff members interviewed supported the claim. During the investigation, LPA Haddadin conducted interviews in two resident rooms and the resident breakroom and did not notice or smell any unpleasant odors.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Samer Haddadin
LICENSING EVALUATOR SIGNATURE:	DATE: 07/21/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2025

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 22-AS-20210324151302

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: CARMEL VILLAGE RETIREMENT COMMUNITY	FACILITY NUMBER: 306005513
	VISIT DATE: 07/21/2025

NARRATIVE

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Concerning the allegation that "staff did not safeguard residents’ personal belongings," the investigation found that none of the three residents or three staff members interviewed supported this allegation. A review of Resident 1's (R1) file showed that the inventory intake sheet, signed and dated on May 10, 2019, listed no personal items. The file also contained email communication from April 5, 2021, between the resident's responsible party and the facility administrator. In this email, the responsible party provided a price list for items for which a refund was requested. Records show a check was issued to R1's responsible party on April 5, 2021, and cleared on May 11, 2021.
As to the allegation that "staff left a resident in soiled clothing for extended periods," none of the three residents or three staff members interviewed corroborated this claim. Furthermore, staff interviews revealed that facility employees conduct routine checks on all incontinent residents at intervals ranging from every 20 minutes to two hours, and also assist residents whenever they request to be changed or refreshed. During the facility tour, LPA Haddadin did not observe any residents in soiled clothing or detect any related odors.
Therefore, based on the preponderance of evidence gathered through interviews, documentation review, and observations conducted by LPA Haddadin, the allegations are deemed UNSUBSTANTIATED. This means that although the alleged events may have happened or are valid, there is not a preponderance of evidence to prove that the violations occurred.
No deficiencies were cited during the visit. An exit interview was conducted, and a copy of this report was provided to the facility

SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Samer Haddadin
LICENSING EVALUATOR SIGNATURE:	DATE: 07/21/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2025

LIC9099 (FAS) - (06/04)

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